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General NPI Number Information
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NPI Number | 1356660393
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Entity Type | Organization
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Legal Business Name | PORTER SQUARE EYE ASSOCIATES INC
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Dates
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Enumeration Date | 05/28/2010
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Last Update Date | 12/12/2024
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Provider Practice Location Address
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Address Line | 2067 MASSACHUSETTS AVE
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City | CAMBRIDGE
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State | MA
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Zip | 02140-1340
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Country | US
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Telephone | 617-864-3147
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Fax |
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Provider Business Mailing Address
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Address Line | 2067 MASSACHUSETTS AVE
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City | CAMBRIDGE
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State | MA
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Zip | 02140-1340
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Country | US
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Telephone | 617-864-3147
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. CRYSTAL J KLAAHSEN
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Credential | O.D.
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Telephone | 617-864-3147
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 4567
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License Number State | MA
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